med feb Flashcards
ECG features of hypoK?
- Prolonged PR
- Prominent U waves
- Flattened T waves
- ST depression
- Possibilitity of re-entrant arrhythmias
Some important side effects of thiazide diuretics?
- Impaired glucose tolerance
- Low K, Na
- High Ca
- Gout
- Dehydration
- postural hypotension
- Impotence
- Rare- pancreatitis
What is the consequence of left ventricular free wall rupture following an MI?
- 3% MIs
- after 1-2wks
- Acute HF secondary to cardiac tamponade (raised JVP, pulsus paradoxus, diminished HS)
Clinical features of Henoch-Schonlein purpura?
APGAR
* Arthralgia
* Palpable purpuric rash, periarticular oedema
* Glomerulonephritis (nephritic)
* Abdo pain
* Renal involvement
Who to refer 2ww for bladder cancer?
Age over 45 and unexplained haematuria w/o UTI
or visible haematuria that persists or recurs after treatment of UTI
or age over 60 and unexplained non visible haematuria + dysuria / raised wcc
Gold standard dx for bladder Ca
Cystoscopy
how to investigate aki of unknown aetiology
Urinary tract USS- check for obstruction- within 24hrs of assessment
Monitoring for henoch schonlein purpura
BP and urinalysis for renal impairment
What happens in CKD bone disease and how to manage it?
- Low vit D, high phosphate, drags Ca out of bone, results in osteomalacia, low Ca, secondary hyperPTH
- Main aim of mx is to reduce phosphate and PTH levels
- Reduced dietary phosphate is 1st line
- Phosphate binders
- Vit D: alfacalcidol, calcitriol
- Parathyroidectomy may be required
When to give IV calcium gluconate as the first option in hyperK?
When the K is > 6.5 mmol/L or if there are ECG changes (do an ecg first if K is less than 6.5)
How to diagnose CKD?
Patients should only be diagnosed with CKD stage 1 if eGFR >90ml/min or stage 2 if eGFR 60-90ml/min if there are markers of kidney disease including proteinuria, haematuria, electrolyte abnormalities or structural abnormalities detected
Causes of renal artery stenosis?
- Atherosclerosis
- Fibromuscular dysplasia- young women esp.
Large volumes of 0.9% NaCl can lead to what?
Hyperchloraemic metabolic acidosis - use hartmanns
When to refer CKD from primary care to secondary care?
- if eGFR falls below 30 or progressively by > 15 in a year
- ACR 70 or more
- uncontrolled resistant htn
- suspected genetic cause
- suspected RAS
- suspected CKD complication
How is diabetes insipidus treated
- Cranial- synthetic forms of vasopressin - desmopressin
- Nephrogenic- thiazide diuretic- helps polyuria
Vomiting acid base disturbance
Metabolic alkalosis
- loss of hydrochloric acid
- loss of potassium and sodium
- kidneys compensate by retaining sodium at the expense of hydrogen ions
Diarrhoea acid base disturbance
normal anion gap acidosis
- GI loss of bicarbonate results in metabolic acidosis
- Normal anion gap due to excretion of bicarb increased
- Hypokalaemia
extra-renal manifestations of ADPKD
- liver cysts- hepatomegaly
- berry aneurysms - SAH
- mitral valve prolapse, aortic root dilatation, aortic dissection
- cysts in other organs such as pancreas and spleen
Lab findings in Paget’s disease of the bone?
- Raised ALP
X-ray in psuedogout
Chondrocalcinosis
Osteoporosis in a man… what to check?
Testosterone- associated w/ higher bone turnover and therefore osteoporosis
Pleural effusion: exudative vs transudative
Exudative- infections pnumonia and TB, malignancy
Transudative- hypoalbuminaemia, ccf, hypothyroid, meig’s
Causes of upper lung fibrosis
CHARTS
C - Coal worker’s pneumoconiosis
H - Histiocytosis/ hypersensitivity pneumonitis
A - Ankylosing spondylitis
R - Radiation
T - Tuberculosis
S - Silicosis/sarcoidosis
Causes of lower zone lung fibrosis
Idiopathic
asbestosis
lupus
drugs
thyrotoxicosis + tender goitre
De quervains thyroiditis (subacute thyroiditis)
DM diagnosis
fasting > 7
random glucose > 11
asymptomatic - 2 readings
hba1c > 48
most sensitivie lab finding in chronic liver disease that can indicate liver cirrhosis?
platelet count
thrombocytopenia
according to bts guidelines, who should have an abg in an acute asthma attack
when o2 sats < 92%
abg is useful to differentiate severe from life threatening as paco2 will be normal or high in life threatening when the pt gets exhausted
describe the histology of coeliacs
villous atrophy, raised intra-epithelial lymphocytes, and crypt hyperplasia
(typically duodenum, jejunal biopsy may be done)
what cancer are coeliacs at a risk of developing
enteropathy-associated T cell lymphoma
what to investigate in high serum calcium
pth
liver + neuro problems…
Wilsons disease
keiser fleischer rings in cornea
green brown rings in periphery of iris
copper accumulation in descemet membrane
wilsons disease!
when are NG tubes safe to use
pH of aspirate < 5.5
how to work out alcohol units
Alcohol units = volume (ml) * ABV / 1,000
What are the 2 main factors contributing to diabetic foot disease
Loss of sensation and peripheral arterial disease is correct. Loss of sensation is due to diabetic neuropathy and results in the loss of protective sensation of the foot - for example, a patient may not notice a stone in their shoe, leading to tissue damage. Chronic high blood sugar levels also cause damage to blood vessels leading to peripheral arterial disease - this causes ischaemia and poor healing of the tissues in the foot.
primary hyperaldosteronism…
high aldosterone: renin ratio
hypertension
low na
low k
ct abdomen with contrast
bilateral venous sampling
most common cause is bilateral adrenal hyperplasia
and then adrenal adenoma
secondary hyperaldosteronism causes
renal artery stenosis
hf
Hydroxychloroquine monitoring
baseline ophthalmological examination
Annual screning thereafter
Can cause bulls eye retinopathy - reduced colour differentiation, reduced central visual acuity, floaters
how does chemo increase gout risk
from increased urate production
Cytotoxic drugs cause increase in cell breakdown, releasing products that are degraded into uric acid
feltys syndrome
RA
splenomegaly
low wcc
Typical presentation of pagets disease of the bone
Older male
Bone Pain
isolated raised ALP
who needs bisphoshphonate when on steroids
offer if T score <1.5 if they are on steroids for >3 months even if < 65yo
high doses of oral steroids- more than 7.5mg prednisolone daily for >3/12
psuedogout aspiration
weakly positively birefringent rhomboid shaped crystals
prophylaxis of gout
Allopurinol + colchicine cover for 6/52
Who needs urate lowering therapy
> 2 attacks in 12 months, tophi, renal disease,
uric acid renal stones, cytotoxic drugs or diuretics
temporal arteritis vision changes
anterior ischaemic optic neuropathy - occlusion of posterior ciliary artery
(a branch of the ophthalmic artery) resulting in ischaemic of the optic nerve head
fundoscopy shows a swollen pale disc and blurred margins
Temporal arteritis can also result in amaurosis fugax
ank spond plain xray features
syndesmophytes- ossifications inside spinal ligaments or of the annulus fibrosus of the intervertebral discs
sacroiliitis- subchondral erosions, sclerosis
squaring of lumbar vertebrae
bamboo spine is late and uncommon
what to do if pt suffers significant upper GI S/E w/ alendronate
Switch to risedronate or etidronate
pts who are allergic to aspirin may also react to what?
sulfasalazine
most common joint for septic arthritis
knee
behcets syndrome triad
oral ulcers, genital ulcers, anterior uveitis
RA joint aspirate
Joint aspirate in rheumatoid arthritis shows a high WBC count, predominantly PMNs. Appearance is typically yellow and cloudy with absence of crystals
The concurrent use of methotrexate and trimethoprim containing antibiotics may cause …
bone marrow suppression and severe or fatal pancytopaenia
drug induced lupus
procainamide
hydralazine
less commonly isoniazid/ minocycline/ phenytoin
what needs correcting prior to starting bisphosphonate
calcium and vit D deficiency
pagets disease xray
mixed lytic and sclerotic lesions
marfan syndrome- defect in which protein?
fibrillin
ehlers danlos-defect in which protein
collagen III
autosomal recessive
widespread elasticity of tissue
main immunoglobulin found in breast milk
igA
main immunoglobulin found in breast milk
igA
systemic sclerosis features
Calcinosis (white deposits)
Raynaud’s (cold, white fingertips precipitated by cold weather)
oEsophogeal dysmotility (dysphagia)
Sclerodactyly (thickened skin on top of hands and inability to straighten fingers)
Telangiectasia (excessive number of spider naevi)
ank spond associated features
Apical fibrosis
Anterior uveitis
Aortic regurgitation
Achilles tendonitis
AV node block
Amyloidosis
septic arthritis causes
staph aureus
young, sexually active- neisseria gonorrhoeae
pts w/ sjogrens have an increased risk of what malignancies
lymphoid
causes of gout
DART
diuretics, alcohol, renal disease, trauma
osteomalacia bloods
raised alp
low calcium
low phos
raised pth
drug induced lupus antibodies
anti histone antibodies
psa vs ra
psa asymmetrical, less likely
ra symmetrical, less likely dactylitis
sle flare monitoring
c4- will be low during flares
what to do if pt in gp suspected pmr but no response to steroid
refer to specialist
consider different diagnosis- PMR very responsive to steroids
- needs to have 70% improvement
polymyositis features
proximal muscle weakness
raised ck
no rash
when prescribing methotrexate what add on therapy should be initiated
folate to reduce BM suppression
dermatomysotis antibodies
ANA
anti jo –> lung fibrosis subtype
anti mil2
Differential diagnoses of polymyalgia rheumatica
rheumatoid arthritis, hypothyroidism, fibromyalgia, and polymyositis.
what type of hypersensitivity is sle
III
sle mnemonic
MD SOAP BRAIN
-Malar Rash
-Discoid Rash
-Serositis (Pericarditis/Pleuritis)
-Oral ulcers
-Arthritis
-Photosensitivity
-Blood disturbance (i.e. anaemia of chronic disease/thrombocytopaenia)
-Renal
-ANA+
-Immunological investigations (dsDNA-ABs/cadiolipin-ABs)
-Neurological (seizures)
pts w/ suspected visual loss secondary to GCA
IV methylpred
allergic contact dermatitis type of hs
type IV hypersensitivty
Bone pain, tenderness and proximal myopathy (→ waddling gait)
?osteomalacia
insulin users sick day rules
same dose
check blood sugars more frequently
copd pts with acute exacerbation & resp acidosis is persisting despite immediate maximum standard medical treatment… what to do
. NIV is required in COPD patients who develop acute respiratory acidosis despite maximum standard medical treatment. NIV increases tidal volume, decreases the respiratory rate and reduces work of breathing. This results in improved oxygenation and decreased hypercapnia.
empyeme pleural effusion aspirate findings
- low glucose because bacteria use it for respiration
- low pH (<7.2) because bacteria producing CO2 in repsiration
- high LDH because lactate dehydrogenase is needed for the bacteria to convert glucose into energy
cushings syndrome u&es findings
hypokalaemia metabolic alkalosis
aspiration pneumonia location & causative agent
right upper zone
klebsiella
produces a red currant jelly sputum
sbp prophylaxis
anyone whos had an sbp episode needs abx prophylaxis to selectively decontaminate the GIT
usually ciprofloxacin is used (or norfloxacin)
what medication should be given to ADPKD to slow down CKD progression
tolvaptan - selective vasopressin antagonist
inhibits the binding of vasopressin to V2 receptors, reduces cell proliferation, cyst fomation, and fluid excretion
this reduces kidney growth (due to cysts, they become ballotable), and protects kidney function
this is the only medication shown to reduce disease progression rather than just symptoms reduction
what medication should be given to ADPKD to slow down CKD progression
tolvaptan - selective vasopressin antagonist
inhibits the binding of vasopressin to V2 receptors, reduces cell proliferation, cyst fomation, and fluid excretion
this reduces kidney growth (due to cysts, they become ballotable), and protects kidney function
this is the only medication shown to reduce disease progression rather than just symptoms reduction
RF aspiration pneumonia
neuro injury
supported feeding
tracheostomy
swallowing difficulty
poor dental hygiene
impaired mucocilliary clearance
(R bases affected, absence of infective cause- no fever)
RF aspiration pneumonia
neuro injury
supported feeding
tracheostomy
swallowing difficulty
poor dental hygiene
impaired mucocilliary clearance
(R bases affected, absence of infective cause- no fever)
subclinical hypothyroidism dx & mx
- TSH raised
- normal thyroid hormones
- no sx
- if tsh remains high on 2 occasions 3 months apart, then offer levothyroxine for 6 months if age < 65
right sided abdo tenderness on dre…
think appendicitis
cxr copd
- hyperinflation
- flattened hemidiaphragms
- hyperlucent lung fields
*
drug causes of cholestasis
- cocp
- abx- co amox, fluclox
- testosterone
- sulphonylurea
Iron defiency anaemia vs. anaemia of chronic disease:
TIBC is high in IDA, and low/normal in anaemia of chronic disease
raised ferritin causes & how to differentiate?
If transferrin saturation is high, consider iron overload, 10% cases
* hereditary haemochromatosis
* secondary iron overload eg following repeated transfusions
if transferrin is low, then high ferritin can be due to:
* inflammation- ferritin is an acute phase reactant
* alcohol excess
* liver disease
* ckd
* malignancy
use of lactulose in liver disease
used in cirrhosis to ensure 2-3 loose stools a day to treat and prevent cases of hepatic encephalopathy
helps clear ammonia from the gut
ammonia builds up in gut for 2 reasons in cirrhosis
1. functional impairment of liver cells preventing them metabolising the ammonia into harmless waste products
2. collateral vessels between the portal and systemic circulation meaning the ammonia bypasses the liver altogether and enters the systemic system directly
features to suggest alcoholic liver disease
ratio ast:alt >2
(>3 is strongly suggestive)
raised gamma GT
Metabolic alkalosis + hypokalaemia →
prolonged vomiting
which UC pts should have regular meds
If a patient with ulcerative colitis has had a severe relapse or >=2 exacerbations in the past year they should be given either oral azathioprine or oral mercaptopurine to maintain remission
check tpmt- risk of BM supression if low/ OD
IBS treatments? (pain/ constip/ diarrhoea)
- pain: antispasmodic agents
- constipation: laxatives but avoid lactulose
- diarrhoea: loperamide is first-line
globus pharyngitis features
- persistent sensation of lump in throat- relieved by swallowing food and drink
- intermittent
- particularly swallowing saliva is difficult
what weight loss is diagnostic of malnutrition
Unintentional weight loss greater than 10% within the last 3-6 months is diagnostic of malnutrition
s/e metoclopramide
- extrapyramidal effects
- acute dystonia e.g. oculogyric crisis
- this is particularly a problem in children and young adults
- diarrhoea
- hyperprolactinaemia
- tardive dyskinesia
- parkinsonism
severe flare of uc mx
- hosp admission
- iv steroids
- iv ciclosporin alt.
- if no improvement within 72hrs give iv ciclosporin too/ consider surgery
TIPSS which vessels
connects hepatic v to portal vein
child with sudden onset dysphagia… what you thinking
benign oeseophageal stricture
rf- tracheo oeseophageal fistula which was repaired
what is asorbic acid
vitamin c
acute mesenteric ischaemia 1st line ix
raised alctate (abg/vbg)
most common cause hepatocellular carcinoma
hepatitis B most common cause worldwide
hepatitis C most common cause in Europe
Budd-Chiari syndrome
triad of sudden onset abdominal pain, ascites, and tender hepatomegaly
(hepativ vein thrombosis causing portal hypertension)
Budd-Chiari syndrome
triad of sudden onset abdominal pain, ascites, and tender hepatomegaly
(hepativ vein thrombosis causing portal hypertension)
recurrent c diff mx
- within 12 wks- oral fidaxomycin
- after 12 wks- oral fidax or oral vanc
pigment laden macrophages within mucosa on PAS staining of colon
laxative abuse causing melanosis coli
abnormal pigmentation of the large bowel due to the presence of pigment-laden macrophages
may be associated with ileal ulcers, polyps and adenomas
monitoring in HH
serum ferritin
transferrin saturation
how can crohns cause gallstones
- terminal ileitis- this is where bile salts are reabsorbed- so messes up the absorption predisposing pts to gallstones
nafld associated factors
- obesity
- type 2 diabetes mellitus
- hyperlipidaemia
- jejunoileal bypass
- sudden weight loss/starvation
ix + mx for mallory weiss syndrome
repeated vomiting- mucour membrane lacerations at the gastroesophageal junction
ix- endoscopy
mx- ablation
R vs L sided colon cancers
- Right-sided colon cancers – abdominal pain, iron-deficiency anaemia, palpable mass in right iliac fossa, often present late
- Left-sided colon cancers – rectal bleeding, change in bowel habit, tenesmus, palpable mass in left iliac fossa or on PR exam
3 features to assess severity of UC
1) number of loose stools a day, blood?
2) systemic features such as fever, tachycardia, abdo tenderness/ distension/ reduced bowel sound
3) ESR/ CRP raised?
extra-intestinal manifestations of UC
arthritis
psc
uveitis
apart from endoscopic intestinal biopsy, what other ix can be done for coeliacs?
- serology- tissue transglutaminase (TTG) antibodies (igA)
- endomyseal antibody )igA)
- check iga levels too
- Genetic screen- HLA DQ2/ DQ8
give 4 mx strategies of LBP
1) nsaids are 1st line- paracetamol monotherapy has been shown to be relatively ineffective. co-prescribe ppi if age > 45
2) exercise programme- group exercise programme within the NHS
3) manual therapy- spinal manipulation, mobilisation or soft tissue techniques such as massage
4) radiofrequency denervations
5) epidural injections of local anaesthetic and steroid for acute and severe sciatica
give 4 mx strategies of LBP
1) nsaids are 1st line- paracetamol monotherapy has been shown to be relatively ineffective. co-prescribe ppi if age > 45
2) exercise programme- group exercise programme within the NHS
3) manual therapy- spinal manipulation, mobilisation or soft tissue techniques such as massage
4) radiofrequency denervations
5) epidural injections of local anaesthetic and steroid for acute and severe sciatica
initial therapy for RA
In 2018 NICE updated their rheumatoid arthritis guidelines. They now recommend DMARD monotherapy +/- a short-course of bridging prednisolone. In the past dual DMARD therapy was advocated as the initial step.
monitoring of response to treatment in RA
- CRP and disease activity score DAS 28
pt with RA, tried 2 DMARDs, inadequate response, what now?
- TNF inhibitors
- etanercept: recombinant human protein, acts as a decoy receptor for TNF-α, subcutaneous administration, can cause demyelination, risks include reactivation of tuberculosis
- infliximab: monoclonal antibody, binds to TNF-α and prevents it from binding with TNF receptors, intravenous administration, risks include reactivation of tuberculosis
- adalimumab: monoclonal antibody, subcutaneous administration
sclerodactyly hand changes
- puffy swollen hands- dactylitis
- thickening and hardening of skin due to fibrosis- sclerodactyly- firstly in fingers then hands and face
- contractures- claw deformities
causes of raynauds
- rheumatological- RA, SLE, scleroderma is most common
- leukaemia
- use of vibrating tools
- oral contraceptive pill
- cervical rib
name 4 drugs causing PF
- methotrexate
- cyclophosphamide
- amiodarone
- nitrofurantoin
rash in reactive arthritis
circinate balanitis (painless vesicles on the coronal margin of the prepuce)
keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles)
virchows triad
hypercoaguable
stasis of blood flow
endothelial injury
explain SVTs briefly
you have an electrical signal re-entering the atria, causing an extra ventricular contraction
if the source is AVN = avnrt
if the source is an accessory pathway = avrt = eg WPW
if the source is somewhere in the atria itself = atrial tachycardia/ flutter/ fibrillation.
and then the pathway tachycardia als for acute. for chronic main thing is wpw’s mx as radiofrequency ablation
WPW ecg
short PR
wide QRS
delta wave
causes of infective endocarditis related to their relations
- staph aureus- most common overall
- strep viridans- poor dental hygiene
- staph epidermidis- for 2/12 following prosthetic valve replacement
- strep bovis- colorectal ca
- SLE (non infective)
cardiac tamponade
becks triad
hypotension + muffled (distant) heart sounds + elevated JVP
dyspnoea
tachycardia
an absent Y descent on the JVP - this is due to the limited right ventricular filling
pulsus paradoxus - an abnormally large drop in BP during inspiration
Kussmaul’s sign - much debate about this
ECG: electrical alternans
posterior MI ecg- which coronary artery
- reciprocal stemi changes in v1-v3 i.e. st depression, tall R waves, dominant r wave V2
- st elevation seen in v7-9
- usually left cx
- sometimes rca
causes of lbbb
new lbbb= myocardial infarction
diagnosing a myocardial infarction for patients with existing LBBB is difficult
rhe Sgarbossa criteria can help with this - please see the link for more details
hypertension
aortic stenosis
cardiomyopathy
rare: idiopathic fibrosis, digoxin toxicity, hyperkalaemia
causes of rbbb
normal variant - more common with increasing age
right ventricular hypertrophy
chronically increased right ventricular pressure - e.g. cor pulmonale
pulmonary embolism
myocardial infarction
atrial septal defect (ostium secundum)
cardiomyopathy or myocarditis
causes of rbbb
normal variant - more common with increasing age
right ventricular hypertrophy
chronically increased right ventricular pressure - e.g. cor pulmonale
pulmonary embolism
myocardial infarction
atrial septal defect (ostium secundum)
cardiomyopathy or myocarditis
s/e doxazosin
postural hypotension
drowsiness
dyspnoea
cough
if a pt declines statin, are there any alternative drugs that can be used?
fenofibrate
surgical options for aortic stenosis
options for aortic valve replacement (AVR) include:
surgical AVR is the treatment of choice for young, low/medium operative risk patients. Cardiovascular disease may coexist. For this reason, an angiogram is often done prior to surgery so that the procedures can be combined
transcatheter AVR (TAVR) is used for patients with a high operative risk
balloon valvuloplasty
may be used in children with no aortic valve calcification
in adults limited to patients with critical aortic stenosis who are not fit for valve replacement
criteria for stemi
2.5 mm (i.e ≥ 2.5 small squares) ST elevation in leads V2-3 in men under 40 years, or ≥ 2.0 mm (i.e ≥ 2 small squares) ST elevation in leads V2-3 in men over 40 years
1.5 mm ST elevation in V2-3 in women
1 mm ST elevation in other leads
new LBBB (LBBB should be considered new unless there is evidence otherwise)
bp 180/ 120 who to refer for same day assessment
- retinal haemorrhage or papilloedema
(accelerated hypertension) or - life-threatening symptoms or
- suspected pheochromocytoma
htn bp targets
below 135/85 mmHg for adults aged under 80
below 145/85 mmHg for adults aged 80 and over.
signs of infective endocarditis
cardiac murmur- Ar/ MR
signs of HF
janeway lesions- palm/ soles of feet- painless
osler nodes- ouch- fingertips
roth spots- in the retina
splinter haemorrhages- nail
splenomegaly- splenic abscess
bb or ccb od
glucagon
ix for aaa rupture
ct angiogram chest/abdo/pelvis - false lumen
if too unstable- toe
cxr- widened mediastinum
nicorandil- use & s/e?
stable angina- 3rd line when ace/bb not tolerated
ulceration anywhere in git- mouth to anus
Diastolic murmur + AF →
?mitral stenosis
may present with stroke/tia
Causes of AR
can be due to valve disease (e.g. bicuspid aortic valve, aortic dissection, spondyloarthropathies (e.g. ankylosing spondylitis) and connective tissue disease) or due to aortic root disease (e.g. rheumatic fever, calcific valve disease, infective endocarditis and connective tissue diseases).
what murmur can cause haemoptysis
mitral stenosis
loud s1 with opening snap
mitral stenosis
rheumatic fever
statins moa
Statins inhibit HMG-CoA reductase, the rate-limiting enzyme in hepatic cholesterol synthesis
recurrent episodes of collapse and a normal resting ECG- what to do now?
24-hour Holter monitor would be pertinent to investigate for any abnormal arrhythmias causing recurrent collapse. Findings on a 24-hour Holter may reveal; sinus pauses, abnormal bradycardia, supraventricular tachycardia or non-sustained ventricular tachycardia. Further investigations will be guided on the 24-hour Holter monitor findings. For example recurrent episodes of non-sustained ventricular tachycardia may warrant a coronary angiogram to investigate for underlying coronary artery disease as a potential precipitant.
do beta blockers cause prolonged qt
not usually
however sotalol does
acute asthma mx
- High flow O2 to achieve sats 94-98%
- 5mg salbutamol, via O2-driven nebuliser, repeat every 20-30 mins
- 40-50mg prednisolone PO (continued for at least 5 days)
- Add nebulised ipratropium bromide 500mcg (SAMA) to SABA treatment
- IV magnesium sulphate single dose (1.2-2g infusion over 20 mins)
- IV aminophylline (following senior discussion)
- ITU/ HDU input intubation + ventilation, ECMO
a. For pts failing to respond to therapies, evidenced by: deteriorating PEF, persistent/ worsening hypoxia, hypercapnia, ABG showing acidosis, exhaustion, feeble respiration, drowsy, confused, altered consciousness, respiratory address - Continue normal ICS as per usual dose
criteria for discharge following acute asthma admission
stable on discharge meds for 12-24 hrs (i.e. no nebs or o2 required)
inhaler technique checked and recorded
pef >75% best or predicted
criteria for discharge following acute asthma admission
stable on discharge meds for 12-24 hrs (i.e. no nebs or o2 required)
inhaler technique checked and recorded
pef >75% best or predicted
who gets ltot copd
Offer LTOT to patients with a pO2 of < 7.3 kPa or to those with a pO2 of 7.3 - 8 kPa and one of the following:
* secondary polycythaemia
* peripheral oedema
* pulmonary hypertension
histological features of chronic asthma
i. Smooth muscle cells hypertrophy
ii. Thickened basement membrane
iii. Goblet cell hyperplasia
a. How do you differentiate pleural effusion from consolidation?
i. Pleural effusion: homogenous opacification, meniscus
ii. Consolidation: heterogenous opacification
c. What are the specific risks of bronchoalveolar lavage that you warn this patient about?
can diagnose pneumonia or ILD- extrinsiv allergic alveolitis as a cause of ILD will show raised lymphocytes and mast cells (hypersensitivity pneumonitis)
risks- haemoptysis, sore throat, pneumothorax, infection
name 3 hereditary causes of thrombosis
- antiphospholipid syndrome
- antithrombin deficiency
- protein C or S deficiency
- factor V Leiden
- polycythaemia rubra vera
what needle for pleural effusion aspiration & where to put the needle?
i. Patient is sat upright with their back slightly flexed
ii. 21g needle placed 2-3 spaces below the level of the meniscus
Organisms which may colonise CF patients
Staphylococcus aureus
Pseudomonas aeruginosa
Burkholderia cepacia*
Aspergillus
CAP causes
- Streptococcus pneumoniae (accounts for around 80% of cases)
- Haemophilus influenzae
- Staphylococcus aureus: commonly after influenza infection
- atypical pneumonias (e.g. Due to Mycoplasma pneumoniae)
- viruses
PE ECG
i. Tachycardia
ii. Right sided heart strain – T-wave inversion
iii. S1Q3T3 – S wave depression in lead 1, pathological q wave and T-wave inversion in leads 3
tb mx & a/e
Drug adverse effects
rifampicin
potent liver enzyme inducer
hepatitis, orange secretions
flu-like symptoms
isoniazid
peripheral neuropathy: prevent with pyridoxine (Vitamin B6)
hepatitis, agranulocytosis
liver enzyme inhibitor
pyrazinamide
hyperuricaemia causing gout
arthralgia, myalgia
hepatitis
ethambutol
optic neuritis: check visual acuity before and during treatment
causes of copd infective exacerbation
bacteria
Haemophilus influenzae (most common cause)
Streptococcus pneumoniae
Moraxella catarrhalis
respiratory viruses
account for around 30% of exacerbations
human rhinovirus is the most important pathogen
eosinophilia + bronchiectasis…
- Allergic bronchopulmonary aspergillosis
- allergy to Aspergillus spores
- eosinophilia and bronchiectasis
- mx- glucocorticoids; itroconazole
atelectasis mx
positioning the patient upright
chest physiotherapy: breathing exercises
(occurs 72hrs post op where alveoli collapse)
causes of bilateral hilar lymphadenopathy
The most common causes of bilateral hilar lymphadenopathy are sarcoidosis and tuberculosis.
Other causes include:
lymphoma/other malignancy
pneumoconiosis e.g. berylliosis
fungi e.g. histoplasmosis, coccidioidomycosis
chest drain location
safe triangle
The triangle is located in the mid axillary line of the 5th intercostal space. It is bordered by:
Anterior edge latissimus dorsi, the lateral border of pectoralis major, a line superior to the horizontal level of the nipple, and the apex below the axilla
cxr-cavitating lung lesion
abscess (Staph aureus, Klebsiella and Pseudomonas)
squamous cell lung cancer
tuberculosis
Wegener’s granulomatosis
pulmonary embolism
rheumatoid arthritis
aspergillosis, histoplasmosis, coccidioidomycosis
give 3 causes of clubbing
Cardiac causes
cyanotic congenital heart disease (Fallot’s, TGA)
bacterial endocarditis
atrial myxoma
Respiratory causes
lung cancer
pyogenic conditions: cystic fibrosis, bronchiectasis, abscess, empyema
tuberculosis
asbestosis, mesothelioma
fibrosing alveolitis
Other causes
Crohn’s, to a lesser extent UC
cirrhosis, primary biliary cirrhosis
Graves’ disease (thyroid acropachy)
rare: Whipple’s disease
key indications for NIV
COPD with respiratory acidosis pH 7.25-7.35
the BTS guidelines state that NIV can be used in patients who are more acidotic (i.e. pH < 7.25) but that a greater degree of monitoring is required (e.g. HDU) and a lower threshold for intubation and ventilation should be used
type II respiratory failure secondary to chest wall deformity, neuromuscular disease or obstructive sleep apnoea
cardiogenic pulmonary oedema unresponsive to CPAP
weaning from tracheal intubation
3 complications following thyroid surgery
- Anatomical such as recurrent laryngeal nerve damage.
- Bleeding. Owing to the confined space haematoma’s may rapidly lead to respiratory compromise owing to laryngeal oedema.
- Damage to the parathyroid glands resulting in hypocalcaemia.
precipitants for DKA
The most common precipitating factors of DKA are infection, missed insulin doses and myocardial infarction.
adverse effects of thiazide diuretics
dehydration
postural hypotension
hyponatraemia, hypokalaemia, hypercalcaemia
gout
impaired glucose tolerance
impotence
rare- pancreatitis
persistent ST elevation following MI
LV aneurysm
The ischaemic damage sustained may weaken the myocardium resulting in aneurysm formation. This is typically associated with persistent ST elevation and left ventricular failure. Thrombus may form within the aneurysm increasing the risk of stroke. Patients are therefore anticoagulated.
what are bronchial breath sounds
harsh breath sounds equally loud on inspiration and expiration
define cerebral palsy
Fixed (non-progressive) neurodevelopmental insult causing abnormalities in development, posture and movement. (can occur between conception and 3 years of age, while the brain is still developing)
define eisenmenger’s syndrome
W h e n a le ft-to -rig h t sh u n t leads to pulm onary hypertension and
sh u n t reversal, therefore tu rn in g an acyanotic h eart defect into a
cyanotic h eart defect
clcnical features of decompensated cardiac congenital disease
P o o r feeding, dypnoea, tachycardia, w eak pulse, cold peripheries,
hepatom egaly, engorged neck veins, sw eating, gallop rhythm
(third h eart sound)
what enzymes do you expect to be risen following cardiac damage
Troponin (I/T), CK-MB, CK, AST, LDH.
ecg changes in MI pt prior to discharge
inverted T waves
pathological Q waves
besides exertion what can trigger angina
Cold/windy weather, emotion (anger/excitement), lying down
(decubitus angina), vivid dreams (nocturnal angina).
signs of pulmonary oedema
Tachypnoea, tachycardia, raised JVP, fine lung crepitations,
wheeze, additional heart sounds/gallop rhythm , dull percussion of
bases, cyanosis, decreased tactile/vocal fremitus. (
complications of htn
hypertensive retinopathy
hypertensisive nephropathy, ckd
mi
hf
stroke, haemorrhage
common causes of af
P neum onia, m ocardial infarction, pulmonary embolism ,
hyperthyroidism , alcohol excess, heart failure, endocarditis.
other than ivdu, give rf for infective endocarditis
Prosthetic valves, patent ductus arteriosis, VSD, coarctation,
mitral valve disease, aortic valve disease (e.g. bicuspid aortic valve).
what is used to grade severity in copd
fev>80- mild
50-79%- mod
30-49- sev
<30- vsevere
signs of consolidation on resp examination
Reduced chest expansion, dull percussion note, increased tactile
vocal fremitus, increased vocal resonance, bronchial breathing.
signs of consolidation on resp examination
Reduced chest expansion, dull percussion note, increased tactile
vocal fremitus, increased vocal resonance, bronchial breathing.
complications bronchiectasis
P neum onia, septicaem ia, recu rren t pneumonia/L R T Is,
haemoptysis, respiratory failure, cor pulmonale, pneumothorax
pul fibrosis cxr
R educed lung volum e, reticulonodular shadow ing (often w orse
in low er zones), honeycom b lung (advanced disease).
OSA questionnaire
epworth sleepiness scale
OSA rf beside obesity
Acromegaly, enlarged tonsils, enlarged adenoids, nasal polyps,
alcohol.
sarcoidosis biopsy
noncaseating granulomas
intermittent claudication in right calf, what artery is likely stenosed
superficial femoral artery or popliteal artery
rf for intermittent claudication
hyperlipidaemia
lack of exercise
diet high in saturated and trans fats
fhx
smoking
what process in the arterial tree can allow intermittent claudication to improve over time
development/ opening up of collateral vessels
how does aspirin work- pharmacological and therapeutic action (2 marks)
irreversible cox inhibitor, which prevents further production from TXA2 (thrmboxane A20 from platelets as they dont have a nucleus
therapeutic actgion- prevents platelet aggregation
where in the lower limb does rest pain typically occur and below what abpi
below 0.5
toes, foot, forefoot
when pt lies on couch, pt with peripheral arterial disease, leg becomes pale
when he stands up again it becomes red
explain this
- when he lies down, the perfusion pressure of the leg is reduced on elevation
- severe ischaemia during elevatin leads to release of local vasodilators eg ADP, potassium CO2, this increases the perfusion of the ischaemc foot when the foot becomes dependent again on returning to the chair
pt with cellulitis
has hypotension and tachycardia
explain the pathophys of this
- bacterial factors (eg exotoxins), induce host inflammatory response
- inflammatory mediators/ cytokines released
- leads to systemic vascular resistance reduced/ increased systemic vascular permeability/ myocardial depression which reduces systemic bp
- in response, activation of sympathetic nervous system, leads to tachycardia, to maintain cardiac output
most common organisms for cellulitis
staphylococcus aureus
grp A strep or streptococcus pyogenes
surgical procedure for improving hearing loss caused by OME
- myringotomy- drains fluid
- grommet insertion- ventilates & equalises pressure across eustachian tube
- adenoidectomy- removes source of infection in the oropharynx
ix for palpitations & why?
- U&Es- ckd or hypoK associated w/ palpitations
- TFTs- hyperthyroidism associated with AF
- echo-structural heart disease or LVH
- ambulatory BP monitoring- look for htn
- ambulating heart rate or rhythm monitoring to look for arrhythmias
- overnight pulse oximetry look for hypoxia overnight
what biochemical abnormality is responsible for the specific damage caused by paracetmaol overdose
glutathione depletion
features of untreated paracetamol OD
HEPATIC ENCEPHALOPATHY
The aetiology is not fully understood but is thought to include excess absorption of ammonia and glutamine from bacterial breakdown of proteins in the gut.
* nausea
* malaise
* jaundice
* confusion
* bleeding
problems with peritoneal dialysis
- bacterial peritonitis
- peritoneal sclerosis
- constipayion
- ultrafiltration failure
- psychosocial effects- changing the dialysis solution and sleeping with a machine each night
risk facgtors for peptic ulcer disease
H. pylori infection, m edications: N S A ID s/steroids, sm oking,
delayed gastric em ptying, physiological stress, e.g. in I T U
patients, hypercalcaem ia, chronic renal failure.
suspected perforated peptic ulcer ix
erect cxr
pneumoperitoneum is seen as free air under the diaphragm
causes of papilloedema
space-occupying lesion: neoplastic, vascular
malignant hypertension
idiopathic intracranial hypertension
hydrocephalus
hypercapnia
causes of tunnel vision
papilloedema
glaucoma
retinitis pigmentosa
choroidoretinitis
optic atrophy secondary to tabes dorsalis
hysteria
